Provider Demographics
NPI:1174626964
Name:SUPERIOR CARE PHARMACY, LLC
Entity Type:Organization
Organization Name:SUPERIOR CARE PHARMACY, LLC
Other - Org Name:OMNICARE OF SALT LAKE CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:
Practice Address - Street 1:2280 W ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-2051
Practice Address - Country:US
Practice Address - Phone:801-266-3999
Practice Address - Fax:801-685-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT36622517043336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275025Medicaid
ID003057600Medicaid
MT1174626964Medicaid
NV2888331Medicaid
WY108128400Medicaid
UT4607795OtherNCPDP
AKPH373UTMedicaid
NV2888331Medicaid